Background: integration of HIV & sexual and reproductive health (SRH) services

1. Do integrated services perform better than stand-alone sites in promoting FP among people living with HIV? A comparative case study from Swaziland Church, K; Fakudze, P; Kikuvi, J; Sikhosana, N; Simelane, D; Wringe, A; Mayhew, S; for the INTEGRA research team International FP Conference, Dakar 29 Nov – 2 Dec 2011 Kathryn Church London School of Hygiene & Tropical Medicine

2. Background: integration of HIV & sexual and reproductive health (SRH) services • Recent calls to deliver a more holistic package of care to people living with HIV (PLWH), to overcome a verticalised approach • Rationale: access to services, cost savings, client satisfaction, reduction in HIV-related stigma, PMTCT (through FP) • While there is growing body of evidence on SRH needs in PLWH, current evidence on impact of integration is weak: • Few studies compare integrated with stand-alone models of care • Measuring the ‘extent’ of current service integration is challenging • Many studies fail to isolate the impact of service reorganisation from other concurrent activities

3. Study aim To investigate whether integrating HIV care and SRH services is an effective model of health care for HIV patients through a comparative analysis of integrated and stand-alone HIV service delivery models in Swaziland. Manzini Clinic A Clinic B Clinic C Clinic D Most “stand-alone” Most integrated

4. Research objectives To investigate the FP practices and needs of PLWH attending HIV care services at the four clinics To investigate whether integrated care is associated with uptake of SRH services and unmet needs for FP To explore the contextual factors influencing the delivery of integrated services within HCTx settings

5. HIV client exit survey: cross-sectional (N=611) Men and women aged 18 and over, attending for pre-ART or ART services Clients identified using systematic random sampling (SRS) Data entry through PDA software (SurveyPlus), imported into STATA 11.0 Chi², analysis of variance and multivariable logistic regression modelling In-depth interviews (IDIs) with 16 providers IDIs with 22 clients (m&f) at ART initiation with follow-up interviews at 2 and 6 months Interviews in SiSwati, transcribed and translated Thematic analysis using Nvivo 8.0 and charting of key themes by case Mixed methods research

6. Participant response rate: 84.7%

7. Results • SRH needs of clients • Service response to SRH needs • Context of integration

8. Results: Description of clinic population

9. Description of clinic population – client type N=166 N=183 N=190 N=72 N=611 p<0.001 Most integrated Most “specialist”

10. Results: unmet need for FP Unmet need = 32% (in DHS among all HIV+ women aged =29%)

11. Clinic A No method Condoms (only) Injectable Clinic B Pills IUD Implants Clinic C LAM Herbal Pills Withdrawal Clinic D 0 20 40 60 80 100 Percent Results: Current contraceptive use (women) N=394 p= 0.035

12. Condom use consistency by type of FP user 45% of respondents classified as consistent condom users Consistent use in those using condoms for pregnancy prevention vs other reasons p<0.001

13. Results • SRH needs of clients • Service response to SRH needs • Context of integration

14. Results: SRH Services accessed since positive HIV test N=603 clients (women=476) N=2345 services

15. Results: SRH service use (multivariable*) 20 Service 10 FP counselling (for women ) 5 Most integrated Most stand-alone Condom provision 2 Counselling on pregnancy (for women) Odds Ratio (95%CI) 1 .5 Outcome: .2 Unmet needs for family planning .1 .05 A B C D Clinic Model

16. Results • SRH needs of clients • Service response to SRH needs • Context of integration

17. Results: Context of service integration • Clinic & policy factors • Physical infrastructure, supplies, client load etc. • Relations between clients and providers • Client factors & provider factors • How integrated does care become?

18. Key contextual influences • Providers and in turn clients ACROSS ALL SITES influenced by a heavy programmatic focus on condom promotion among PLWH. • I: what advice did they give you about family planning [...]? • R: There wasn’t any, they just told me not to have sex without a condom because the people that I have sex with, if they don’t have HIV, I’ll spread it to them and also when I’m taking pills I can reinfect anybody [Female client, stand-alone site] • FP counsellling is focused at the time of ART initiation when clients may not be receptive to counselling messages: • even if you tell [clients] they have to start thinking about [FP], it’s basically the last of their problems most of the time. They only realize later on …so you keep insisting that they go for [FP], but to them it’s an extra mile, they are really concerned about getting back to normal, living their lives, so I think that’s where we lose most of the contact [Provider, stand-alone clinic]

19. Key contextual influences • ART providers are overwhelmed with ART….and may rely on internal referral processes for SRH to other rooms/”units”: “it’s not the only thing that you’re supposed to ask and you’re supposed to do, so you may overlook the family planning issue” [Provider, integrated site] -- but internal referral doesn’t always work! • Even partial integration may lead to de-skilling of providers and loss of confidence in abilities to deliver other services • While providers perceive client benefits to integration, they perceive few personal benefits, and do not consider efficiency gains • Care remains routinsed and task-oriented, i.e. centred on delivery of routine tasks – exploring other client needs remains limited:

20. R: I don’t know what [vaccinations] my baby’s getting and when… I: Oh […] they don’t explain to you what your baby is getting and what it’s for? R: They give you the card with all the information, where each injection is given […]. Other than that, no they don’t say anything. If you’re a mum for the first time, you’re in trouble I: (Laughing) so how come you don’t ask them to explain the shots? R: It’s usually fast… and they usually say they are taking the baby to be weighed, but then they take the baby and do everything, so there is no time to ask a lot of questions I: What about while they are doing it… you don’t ask questions? R: Whoo! There’s not much you can talk about in there… they will just tell you “lift his armpit”, “ turn him around” “rub him” “pick him up” and then it’s over and they have to attend to the next person [Female client, integrated clinic]

21. Conclusions and research implications HIV clinics are doing a good job in promoting condoms among PLWH, but are condoms enough or always the right response? Dual method use may also needs to be encouraged** FP counselling at ART initiation is not sufficient ‘ART providers’ need training to deliver basic contraceptives in their ‘ART rooms’; if this is not feasible, then routine referrals to a very NEAR-BY room should be available Integration needs to be supported by managers to ensure all staff are motivated and capacitated to deliver required services Limitations: Cross-sectional observational design, small no. clinics

22. Partners in Swaziland: the Ministry of Health, the Family Life Association of Swaziland, CSO Research team in Swaziland Clinic staff and managers at FLAS, KSII, RFM & LaMvelase Funders: ESRC/MRC & Bill & Melinda Gates Foundation (INTEGRA Project) INTEGRA partners: IPPF, Population Council Supervisors at LSHTM: Susannah Mayhew & Alison Wringe THANK YOU! kathryn.church@lshtm.ac.uk Acknowledgements